Stanford Court Skilled Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Stanford Court Skilled Nursing & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF758Jan 12, 2023

  Based on interview and record review, the facility failed to ensure four of four sampled residents (Residents 10, 13, 48, 169) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications including Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) and Nuplazid (an antipsychotic medication for Parkinson disease psychosis) when: 1. Resident 10 was administered Seroquel without an appropriate indication and/or clinical justification, no resident-centered behavioral interventions were implemented prior to initiation and during use of Seroquel, inadequate behavioral monitoring was documented during use of Seroquel, and manufacturer specified monitoring were not done during use of… […]

• No harm, potential for more than minimal, widespreadF802Jan 12, 2023

  Based on observation, interview and record review, the facility did not ensure kitchen staff performed their tasks safely and correctly when: 1. a Dishwasher Diet Aide (DA 1) could not correctly test the sanitizer solution (liquid that removes bacteria) on dishes used for resident meals, 2. a Cook (CK) did not know the correct cool down procedure timeframe for cooked meats. As a result, 61 residents who consumed food from the kitchen had the potential to be exposed to bacterial contamination through unsafe meat or unsanitary dishes. Facility Census was 65. Findings: 1. During the initial kitchen tour on 1/9/23 at 8:55 A.M., an observation of the dishmachine and interview with DA 1 was conducted. […]

• No harm, potential for more than minimal, widespreadF812Jan 12, 2023

  Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment that lessened the risk for foodborne illness and cross contamination when: 1. the dish machine sanitation cycle failed to sanitize dishes at the correct sanitizing level, according to facility policy and standards of practice; 2. five cucumbers with a visible substance resembling white mold and multiple dark brown spots were stored and comingled with other cucumbers and vegetables in the walk-in refrigerator; 3. a plastic container of rice and of flour were not labeled or dated with a use by date; and a plastic container of powdered sugar had an expired use by date; and 4. […]

• No harm, potential for more than minimal, patternF578Dec 4, 2025

  Based on interview and record review, the facility failed to ensure written information related to advance directive was provided to 6 of 10 sampled residents (1,12,45, 85, 130, and 144). This failure may affect Resident 1,12, 45, 85, 130, and 144's decision to formulate an advance directive due to lack of knowledge and information. FindingsOn 12/3/25 a review of Resident 1's clinical record was conducted. Resident 1 was admitted to the facility on [DATE] per the facility's admission Record. The facility's document titled Advance Directive Acknowledgement dated 10/16/25, indicated, [ ] I have received the brochure on Advance Directives was left blank. […]

• No harm, potential for more than minimal, patternF689Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure the water temperature in nine residents' rooms (Resident 134, 135, 140, 123, 128, 132, 113, 53, and 147) and the shower room located by the 500 rooms was below 120 degrees Fahrenheit ( F).As a result of this deficient practice, there was the potential for residents using the water to get scalded. Findings:A review of Resident 134's admission Record indicated the resident was admitted to the facility on [DATE].A review of Resident 135's admission Record indicated the resident was admitted to the facility on [DATE].A review of Resident 140's admission Record indicated the resident was admitted to the facility on [DATE].A review of Resident 123's admission Record indicated the resident was admitted to the… […]